Special situations

Not every birth follows the usual pattern. Some babies come early, some come in pairs, some come bottom first, and a few arrive before anyone can get to the hospital. This chapter covers the situations that change how labour and birth are managed.

Preterm labour and birth

A baby born before 37 weeks is called preterm. About one in ten babies arrives early, most of them between 32 and 37 weeks, and most of those do very well.

The signs of preterm labour are the same as at term, only earlier: regular tightenings or period-like cramps, a low backache that comes and goes, pelvic pressure, bleeding, or fluid leaking. Call your midwife or doctor or go to your hospital right away if you have any of these before 37 weeks. It is always better to be checked and sent home.

If birth is likely within a few days, you may be given steroid injections to help your baby's lungs mature, magnesium sulphate through a drip to protect a very early baby's brain, and sometimes medicine to slow contractions for a day or two. You may be moved to a hospital with the right neonatal unit.

The neonatal unit

Babies born early, small or unwell may go to a neonatal intensive care unit (NICU) or special care nursery. The first visit can be overwhelming: alarms, wires, incubators, and a baby smaller than you imagined.

You are not a visitor. You are your baby's parent, and most units welcome parents at any hour. Ask the nurses to explain each machine and what the numbers mean, and how you can help with care: changing diapers, taking temperatures, joining rounds.

Kangaroo care

Kangaroo care means holding your baby skin to skin on your bare chest, often for long stretches, even with tubes in place. It steadies breathing, heart rate and temperature, supports growth and sleep, boosts your milk supply and helps you feel like a parent. Both parents can do it, often from the first days.

Expressing milk

Breast milk is especially protective for preterm babies. If your baby cannot feed at the breast yet, start expressing within the first few hours if you can. Hand expressing works best for the first drops of colostrum, then a hospital-grade pump. Aim for about 8 or more times in 24 hours, including once at night. Every drop counts. If you cannot or choose not to provide your own milk, ask about donor milk; preterm formula is a safe choice too.

Corrected age

Your baby's age is counted from the actual birth, but development is judged by corrected age: their age minus the weeks they were born early. A 4- month-old born 8 weeks early has a corrected age of about 2 months. Use corrected age for milestones until about 2 years. Vaccines usually follow actual age.

Twins and more

Twins are more likely to come early, and many are born around 36 to 37 weeks, often by plan. How they are born depends mainly on how the first baby is lying.

If the first twin is head down, a vaginal birth is often possible and about as safe as a caesarean. Birth usually happens in or near an operating room, with extra staff and a pediatric team for each baby. Both heartbeats are monitored continuously, and an epidural is often recommended so help can be given quickly if the second twin needs it. The second baby usually follows within about half an hour, sometimes with the waters broken, a hormone drip or an assisted birth. If the first twin is not head down, or with three or more babies, a caesarean is usually recommended (see "Caesarean birth").

Breech birth

About 3 to 4 babies in 100 are still breech (bottom or feet first) at term. From about 36 or 37 weeks you may be offered an external cephalic version (ECV), where a doctor turns your baby by pressing firmly on your belly. It works about half the time.

If your baby stays breech, you will usually choose between a planned caesarean and a planned vaginal breech birth. A planned caesarean slightly lowers the risk of serious problems for the baby during birth. A vaginal breech birth avoids surgery and can be a reasonable choice when the baby is a typical size, the bottom is coming first, the head is tucked, and a team skilled in breech birth is available. Ask how much breech experience your hospital has.

Figure 4. Three ways a baby can lie in the uterus near the end of pregnancy.

A very fast or unplanned birth

Occasionally a baby arrives at home or in the car before help does. Most of these babies are healthy. Signs the birth is very close: a strong urge to push you cannot resist, or the baby's head visible at the opening of the vagina.

While you wait for help

• 1. Call your local emergency number and put the phone on speaker. The dispatcher will talk you through each step. Call your midwife too if you have one.
• 2. If you are driving, pull over safely. Do not race the birth.
• 3. Unlock the door and turn on lights so help can get in.
• 4. Gather towels and blankets and lay some under the birthing parent.
• 5. Choose a position on the floor or bed: hands and knees, on the side, or half sitting. Avoid standing, where the baby could fall.

As the baby is born

Do not hold the baby in or cross your legs. Pant through contractions rather than pushing hard, so the head comes out slowly.

Do not pull on the baby, head or cord. The head usually comes first, then the baby turns and the body slides out with the next contraction. Support the baby gently as they come out.

If the cord is loosely around the neck, gently slip it over the head. Do not pull it tight.

Right after the birth

Put the baby straight onto the parent's bare chest, tummy down.

Dry the baby well, especially the head, remove wet towels and cover both of you with a dry blanket.

Check the baby is breathing. Most cry or breathe within a minute. If not, keep rubbing their back firmly, wipe mucus from the nose and mouth, and follow the dispatcher.

Keep everyone warm: close windows, turn up the heat.

Do not cut or tie the cord. Leave it for the team.

Wait for the placenta. It usually comes within 30 minutes to an hour, with cramping and a gush of blood. Do not pull the cord. Put the placenta in a bowl or bag beside the baby, still attached.

Let the baby nuzzle and feed if they want. This helps the uterus contract and slows bleeding.

Get help right away if the baby is not breathing, is floppy, or is blue around the lips after a minute or two of drying and rubbing; if bleeding is heavy or the parent feels faint; or if the cord comes out before the baby. Even when all goes well, both should be checked by a midwife or doctor soon after. Planned home birth and water birth

Home birth

For healthy people with a straightforward pregnancy, especially those who have given birth before, a planned home birth with trained midwives is a safe option where home birth is well supported and transfer to hospital is quick. It generally means fewer interventions. For first births, some studies find a slightly higher risk for the baby, and transfer is more common: roughly 4 in 10 first-time parents are transferred, mostly for slow progress or pain relief, compared with about 1 in 10 of those who have given birth before. Home birth is usually not advised with twins, a breech baby, preterm labour, high blood pressure and some other conditions. Ask your midwife whether it suits you.

Midwives bring monitoring equipment, medicines to control bleeding, equipment to help a baby breathe and a suturing kit. You may be transferred if labour stalls, you want an epidural, the baby's heart rate changes, there is meconium in the waters, or bleeding is heavy after the birth. Most transfers are not emergencies. Keep a bag packed just in case.

Water birth

Labouring in warm water reduces pain and the need for an epidural. Giving birth in the water is a reasonable option for healthy people with a straightforward labour at term, with the water kept at about body temperature. Your midwife will ask you to leave the pool if there is a concern, such as a change in the baby's heart rate, meconium or heavy bleeding. Your baby is brought gently to the surface straight after birth. Vaginal birth after caesarean (VBAC)

If you have had one caesarean with a low, horizontal cut in the uterus, planning a vaginal birth next time is usually a reasonable option. About 60 to 80 percent of planned VBACs end in a vaginal birth. Chances are higher if you have had a vaginal birth before, if labour starts on its own, and if your caesarean was for a reason that will not repeat, such as a breech baby. The main risk is uterine rupture, where the old scar opens during labour. It happens in about 1 in 200 planned VBACs and can be serious for parent and baby. The risk is somewhat higher if labour is induced. A repeat caesarean avoids that risk but brings the risks of surgery, a longer recovery and more placenta problems in future pregnancies.

For a VBAC, plan to give birth in hospital where an emergency caesarean can be done quickly. Continuous monitoring of the baby's heart rate is usually advised, and a drip is often placed. An epidural is fine. Your team watches for warning signs such as a change in the baby's heart rate, new pain between contractions, or bleeding. Decide together with your care provider, and know you can change your mind.

Group B strep

Group B strep (GBS) is a common bacterium that lives harmlessly in the gut and vagina of about 1 in 4 or 5 people. Rarely, it passes to a baby during labour and causes serious infection. You may be tested at about 35 to 37 weeks, or offered treatment based on risk factors.

If you carry GBS, you will be offered antibiotics through a drip from the start of labour or when your waters break, repeated until birth. At least four hours before birth gives the best protection, so go in promptly. Call your baby's doctor or nurse right away if your newborn is unusually sleepy or floppy, feeds poorly, grunts, breathes fast, or is too hot or too cold.

Meconium in the waters

Meconium is a baby's first stool. Sometimes it is passed before birth, staining the waters green or brown. It is often harmless, but can be a sign of stress. If your waters are stained, call your midwife or hospital and go in. The baby's heart rate is usually monitored continuously, and a pediatric team may be at the birth. A baby who is breathing well can still go straight to your chest.

Giving birth after a loss or trauma

If you have lost a baby before, or had a frightening birth, labour can bring up strong feelings even when all is going well. Tell your care team early. Many can offer extra appointments, a named midwife or counselling. Write down what helps you, such as being told before each examination, fewer people in the room, or a particular light kept on. If you have experienced sexual violence, you can ask for staff of a particular gender and for examinations to be kept to a minimum. Share as much or as little as you want. "When birth doesn't go as hoped" says more.

If a baby dies

Very rarely, a baby dies before or during birth. If this happens to you, nothing you did caused it, and no one will rush you. Your care team will guide you gently through the birth and what comes after. You can take time with your baby, hold them, name them, dress them, take photographs, and keep handprints or a lock of hair, if and when you wish. Many hospitals have bereavement midwives and support organizations to walk alongside you. You do not have to carry this alone.

In short

Call right away for any signs of labour before 37 weeks. In the neonatal unit, kangaroo care and your own milk help your baby.

Twins and breech babies may be born vaginally or by caesarean, depending on how they lie and on the team's skills.

In a very fast birth: call emergency services, do not pull, dry the baby, hold them skin to skin, keep warm, and leave the cord and placenta for the team.

About 60 to 80 percent of planned VBACs succeed, with a small risk of the scar opening.

If you carry Group B strep, go in early in labour for antibiotics. After a loss or a hard birth, tell your team what you need.